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comprehensive nclex exam answer key

comprehensive nclex exam answer key



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Published by Amy
lord of fajitas is the king!! but my class liked this so in case u don't have
lord of fajitas is the king!! but my class liked this so in case u don't have

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Published by: Amy on Apr 17, 2009
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40 items Comprehensive NCLEX review answer key
1. Which individual is at greatest risk for developing hypertension?
A) 45 year-old African American attorney
 B) 60 year-old Asian American shop ownerC) 40 year-old Caucasian nurseD)55 year-old Hispanic teacherThe correct answer is A: 45 year-old African American attorney Theincidence of hypertension is greater among African Americans thanother groups in the US. The incidence among the Hispanic populationis rising.2. A child who ingested 15 maximum strength acetaminophen tablets45 minutes ago is seen in the emergency department. Which of theseorders should the nurse do first?
A) Gastric lavage PRN
 B) Acetylcysteine (mucomyst) for age per pharmacyC) Start an IV Dextrose 5% with 0.33% normal saline to keep veinopenD) Activated charcoal per pharmacyThe correct answer is A: Gastric lavage PRN Removing as much of thedrug as possible is the first step in treatment for this drug overdose.This is best done by gastric lavage. The next drug to give would beactivated charcoal, then mucomyst and lastly the IV fluids.3. Which complication of cardiac catheterization should the nursemonitor for in the initial 24 hours after the procedure?A) angina at rest
B) thrombus formation
C) dizzinessD) falling blood pressureThe correct answer is B: thrombus formation Thrombus formation inthe coronary arteries is a potential problem in the initial 24 hours aftera cardiac catheterization. A falling BP occurs along with hemorrhage of the insertion site which is associated with the first 12 hours after theprocedure.4. A client is admitted to the emergency room with renal calculi and iscomplaining of moderate to severe flank pain and nausea. The client’stemperature is 100.8 degrees Fahrenheit. The priority nursing goal forthis client isA) Maintain fluid and electrolyte balanceB) Control nausea
C) Manage pain
 D) Prevent urinary tract infectionThe correct answer is C: Manage pain The immediate goal of therapyis to alleviate the client’s pain.5. What would the nurse expect to see while assessing the growth of children during their school age years?A) Decreasing amounts of body fat and muscle massB) Little change in body appearance from year to yearC) Progressive height increase of 4 inches each year
D) Yearly weight gain of about 5.5 pounds per year
 The correct answer is D: Yearly weight gain of about 5.5 pounds peryear School age children gain about 5.5 pounds each year andincrease about 2 inches in height.6. At a community health fair the blood pressure of a 62 year-oldclient is 160/96. The client states “My blood pressure is usually muchlower.” The nurse should tell the client to
A) go get a blood pressure check within the next 48 to 72 hours
 B) check blood pressure again in 2 monthsC) see the health care provider immediatelyD) visit the health care provider within 1 week for a BP checkThe correct answer is A: go get a blood pressure check within the next48 to 72 hours The blood pressure reading is moderately high with theneed to have it rechecked in a few days. The client states it is ‘usuallymuch lower.’ Thus a concern exists for complications such as stroke.However immediate check by the provider of care is not warranted.Waiting 2 months or a week for follow-up is too long.7. The hospital has sounded the call for a disaster drill on the eveningshift. Which of these clients would the nurse put first on the list to bedischarged in order to make a room available for a new admission?
A) A middle aged client with a history of being ventilatordependent for over 7 years and admitted with bacterialpneumonia five days ago
 B) A young adult with diabetes mellitus Type 2 for over 10 years andadmitted with antibiotic induced diarrhea 24 hours agoC) An elderly client with a history of hypertension,hypercholesterolemia and lupus, and was admitted with Stevens-Johnson syndrome that morningD) An adolescent with a positive HIV test and admitted for acutecellulitus of the lower leg 48 hours ago
The correct answer is A: A middle aged client with a history of beingventilator dependent for over 7 years and admitted with bacterialpneumonia five days ago The best candidate for discharge is one whohas had a chronic condition and is most familiar with their care. Thisclient in option A is most likely stable and could continue medicationtherapy at home.8. A client has been newly diagnosed with hypothyroidism and willtake levothyroxine (Synthroid) 50 mcg/day by mouth. As part of theteaching plan, the nurse emphasizes that this medication:
A) Should be taken in the morning
 B) May decrease the client's energy levelC) Must be stored in a dark containerD) Will decrease the client's heart rateThe correct answer is A: Should be taken in the morning Thyroidsupplement should be taken in the morning to minimize the sideeffects of insomnia9. A 3 year-old child comes to the pediatric clinic after the suddenonset of findings that include irritability, thick muffled voice, croakingon inspiration, hot to touch, sit leaning forward, tongue protruding,drooling and suprasternal retractions. What should the nurse do first?A) Prepare the child for x-ray of upper airwaysB) Examine the child's throatC) Collect a sputum specimen
D) Notify the healthcare provider of the child's status
 The correct answer is D: Notify the health care provider of the child''sstatus These findings suggest a medical emergency and may be due toepiglottises. Any child with an acute onset of an inflammatoryresponse in the mouth and throat should receive immediate attentionin a facility equipped to perform intubation or a tracheostomy in theevent of further or complete obstruction.10. In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents totake their school age child for evaluation?A) PolyphagiaB) Dehydration
C) Bed wetting
 D) Weight lossThe correct answer is C: Bed wetting In children, fatigue and bedwetting are the chief complaints that prompt parents to take their childfor evaluation. Bed wetting in a school age child is readily detected by

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